Killing and Letting Die

Intentional killing is prohibited. So is the presumption of evil intent.

The patient. At a Mercy Hospital in the Midwest, Steven Becker, a 28 year-old husband and father, lies in what is called a persistent vegetative state (P.V.S.) brought on six months ago when a cyst cut off blood in his brain. In the absence of advance directives, a hospital ethics committee recommended - with his wife eventually concurring - that he be disengaged from the tubes providing nutrients and water. Becker’s mother, apparently thinking that her son might be locked in (with damage to the brain stem, rather than to the higher portions of the brain crucial to exercise conscious powers), has won a court order preventing the removal of the tubes. His fate is now in the hands of legal proceduralists.

Some things might be noted. 1) PVS is not an irreversible diagnosis, since a small percentage of patients have emerged from such a condition. PVS patients are not vegetables; they are, rather, profoundly damaged human persons. 2) It seems strange that brain scans should have failed to reveal where the damage to the brain actually is. This would clarify any debate whether the young man is locked in or not. In fact, most locked-in patients are able to respond to requests by lateral or vertical movement of their eyes, even if they cannot voluntarily blink. 3) The absence of a living will or advance directives should not be germane. If the removal of tubes is intentional killing, it should be morally proscribed whether the patient wants it or not.

The protesters and commentators. Some sign carriers suggest that removing nutrition and hydration tubes is worse than using a gun to kill someone. Others question the mercy of the hospital bearing its name. News stories and opinion pieces have been polarized. Terms like pulling the plug (which has no application in this case) and starving to death (which is an over-simplified description of what might happen) are bandied about. Many people on both sides presume that quality of life is a central factor in determining the choices to be made.

And here a few things should be said, too. 1) It is an unjust and uncharitable assumption to presume the ill will of persons by attributing the intent to kill and mercilessness to their actions. 2) One must be very careful and honest in understanding and naming the cause of death. Is refusal or withdrawal of treatment really tantamount to intentional killing? 3) It is possible to hold that quality of life is a factor in choosing treatment and at the same time hold that diminished quality of life is never an acceptable reason for intentionally killing a human being.

The Culture. A strong case can be made that we inhabit a culture of death. In some respects, we have indeed reached the morally bankrupt position where we think we can eliminate illness by killing the ill. We do not approach a slippery slope. We have moved over the edge of the abyss in these matters of choosing death for those at the margins of lifethe very young, the very old, the very wounded. In this regard, I align myself with those who hold the absolute prohibition against the intentional killing of even the least human person. But this does not mean that I concur with those who throw accusations at persons and institutions who advise, under appropriate conditions, the withdrawal of treatment. It cannot be required of persons that they use every technology available to prolong dying or postpone death. If that is the case, we ought first to provide minimal food, drinking water and health care to the desperately poor of the world, rather than amass medical technology to ease our own inordinate fear of death.

Another Option. In his wise and challenging book The Troubled Dream of Life, Daniel Callahan reminds us that artificial nutrition and hydration were originally short-term treatments for postsurgical patients. The procedure, soon after utilized for any patient unable to eat or drink, no matter what the conditions, eventually was taken for basic care rather than a treatmenteven though in the past, and still in most parts of the world, the process of dying is accompanied by the inability to take food and water. Where once nature had killed people by robbing their bodies of the capacity to take nutrition, now the blame has been shifted to the human beings who failed to provide artificial nutrition.

Let us be clear. In medical ethics issues, the particularities of a patient’s condition, the best prudential judgment of caregivers, and the expressed (or presumed) wishes of a patient are found in wide variety. Inflexible standards for treatment cannot be applied like generic pills. But there are some general moral principles that hold. Intentional killing is prohibited. So is the presumption of evil intent. One cannot and ought not assume that the physician who recommends the withdrawal of treatment is intentionally killing a patient. Not only is this an unjust attribution of intent; it is contradicted by any case where a treatment has been stopped and the patient has continued to live.

Those who equate withdrawal of treatment with intentional killing misunderstand health care and caregivers. They also distort moral reasoning. Both sides have a point in the case of young Steven Becker. And neither, we may hope, intends mercilessness or murder. They differ in their prudential judgment. And both sides should exercise vigilance over their own motives.

John F. Kavanaugh, S.J., is a professor of philosophy at St. Louis University in St. Louis, Mo.